Dr. Gian Pietro Schincaglia received his Dental degree from the University of Ferrara in Italy and his Periodontal Certificate from the University of Southern California. Since 2003 he has been a Diplomate of The American Board of Periodontology and in 2006 he received his PhD degree in bone biology from the University of Ferrara. From 2007 to 2014 he was Associate Professor in Periodontology and Director of the Graduate Program in Periodontology at the University of Connecticut. He is currently the Chair and Post Graduate Program Director of the Department of Periodontology at WVU. He has been published extensively in peer-review journals. His research activity is focused on implant immediate loading, peri-implant mucositis, periodontal regeneration and bone biology.
VIDEO - DUwHF #1549 - Gian Pietro Schincaglia
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Dr. Gian Pietro Schincaglia it's just a huge honor for me today to be podcast interviewing Dr. Gian Pietro Schincaglia DDS PhD he received his dental degree from the university of Ferrari Italy which i assume is why he drives a red Ferrari and the periodontal certificate from the university of southern California los Angeles since 2003 he is a diplomat of the American board of periodontology and in 2006 he received his PhD degree in bone biology from the university of Ferrari from 2007 to 2014 he was associate professor in periodontology and direct your graduate program at the university of Connecticut and is now chair and postgraduate program director of the department of periodontology at west Virginia university he has been published extensively in peer-reviewed journals his reach act research activity is focused on implant immediate loading peri-implant mucus mucositis periodontal regeneration and bone graft and gianna i cannot tell you what an honor it is to have you come on the show i know you're busier than a one-armed dennis thank you so much for coming on the show today how are you doing very good very good thank you ower for having me this is my first podcast in my life so that's gonna be a very interesting experience and i look like you're on fire so i try to warm up too well I’ll tell you what it can only go up you're starting with the worst dental podcast on the internet so it could only get better from this one on out but i have to i i want to start out first since you have two doctorates that um everyone wants to know would you take the vaccine today yes of course actually part of my uh doctorate project was to work i work on a early application of the liposome [Music] transfection using DNA at the time we were looking at some methodology to modify the expression of the bone cells to produce more bone if in case of osteoporosis that was an in vitro study because for many many years the use of liposome technology was forbidden and it was just limited for very few conditions and this i think is going to be a breakthrough [Music] of science and this is if something good this year brought with to us which is very limited amount is probably this breakthrough through technology and and science and you can see the same technologies apply to cancer now and you may develop vaccine for cancer using this platform well who cares about cancer i want to know about hair loss are they going to be able to grow my hair me too we are in the same boat oh my gosh well i remember the good news when i was a freshman at Creighton the big news on tv was that up john pharmaceuticals in Kalamazoo Michigan cured male pattern baldness with minoxidil drops and uh so i bought my drops and it was so much money and I’m pretty sure it didn't work so uh uh i don't know i don't i don't get my hopes up too easy anymore um you know i i want to start out you know we have so many kids watching this show a quarter of them are in dental school i know you're in the proscad uh program uh so you're gonna yeah so but you get to see the undergrads um you know those kids you know there's when i got out of school there were eight specialties there was uh and now there's 12. and um you know you are talking about implantology bone grafting a lot of people say how did we had oral surgery endodontics perio pediatric ortho pros dental anesthesia and now they've added oral facial pain oral med oral path or radiology and i forgot the dental public health a lot of people were saying that it should have been um implants uh implantology should have been a specialist it seems kind of divided between oral surgery perio um what would you say uh to people who say well because that's what you do i mean i mean you're an implant specialist i mean you you all you're you've got two doctorates you're on implants immediate loading period implant mucositis periodontal degeneration bone biology how do you distinguish between oral surgeon periodontists and implantologist well uh implant dentistry is across um is a crocessional type of specialty that involved is mainly a restorative restorative discipline with the extension of the surgical component so um is multidisciplinary i have no um i have no problem to have a prosthodontist or and um other specialties encroaching with implants of course you need to uh to have a broader view of the discipline it's just it's not just surgery it's not just restorative it's a combination so perio for many many years has been basically working with pros before implant in restoring and recall and recuperating teeth for fix uh restoration right and that's what probably lead to perio to be closer to in communication in collaboration with the prospect group that's what happened here at wvu we have a great collaboration between the two departments that is generating research and new approaches and new technology and the use of a full digital workflow for each one and the game um is the important thing is to have a comprehensive understanding of oral health and of course i have to push a little bit toward my side um perio has been is the only specialty that includes also in the board uh board certification in periodontics and dental implant surgery so we're a little bit ahead of the game in terms of qualification if you will uh other than that i think is everybody's game it's no there's no no specialty is better than the other of course this cover practice oral surgery is broader they can work on more as severe atrophic edentulous sites and full arch rehabilitation but for perry is more toward aesthetic and detail so it's like you know working on different metrics sometimes well you know your dean i love your dean photo um his real name is uh photonos s penang panagados how do you say that i know it's greek yeah we have we always have a debate between italians and greeks so well I’ll tell you what he's gonna do did you ever see that movie uh my big fat greek wedding uh yeah yeah he's gonna try to go to the proso department have everybody spray windex on the inside of the crown so they they see it easier that's the uh that's the greek's most famous trick um my gosh but i i want to um i just want to point out to the kids before i get into this that you know i love it when i hear you and you come out of school and you're bright-eyed and bushy-tailed and you tell me you want to learn oral surgery and root canals and perio and silver diamine fluoride and you want to learn orthodontics invisalign you want to learn all these things but i mean look at look at this guy i mean i mean my gosh it's all coming down especially i mean to place an implant you got to know about implants immediate loading period implant mucositis periodontal regeneration bone biology um my gosh i mean kids um my advice is that you come out of school and you become you spend 10 000 hours which takes you about 10 years to become the very best in one thing and if you think you're gonna be the best in 12 different specialties um you're going to have to live to be at least 200 years old um so i just uh my gosh so i love your enthusiasm but you gotta focus because i walked away from implants i i have a um my diplomat international congressman on plantology i got my fellowship in the missions too but i got it when the new the new cbct of the day back in night now what was in 1987 was when they did that software upgrade so the pano would show an r on one side and an l on the other and that was the greatest radiographic invention of all time and um and all the people who taught me implantology were doing it with a pano there was no 3d and and what got me out of it was that i realized just for me to understand the bone grafting around it was going to be another 80 gazillion hours of continuing education and i thought you know what there's there's oral surgeons and periodonts on the street I’m it's just too much you can't master 12 specialties so what um so i um the reason I’m going to get back into place implants because i know we're just like two days away where i can sit in my jacuzzi drinking a beer and my yomi robot uh will place the implant do i even have to get out of the jacuzzi and put down my beer or will you do it all yeah I’m gonna have to do that well the year that's bad news yeah we have to do it uh i think that the uh the robotics is the future the reason why i push and i had a great support of portinos here at uh and the previous dean dr borja i have to give him a credit uh they were very supportive to to include this technology here wvu um i think the digital the digital workflow and the digi everything is going to be digital you said from starting from podcasting and a tone um it's not going to be a replacement of us as a professional it's going to just improve the quality and the precision the plan for the yomi is also to include uh algorithm for uh crown prep and for uh uh root canal so that's gonna be you know the the futurable situation is gonna be a lot of robots walking uh being in the pro in in in practices to improve the quality of the of the treatment right now is not mean the workflows needs improvement although it's already improved a lot the but the precision once the patient is connected to the machine is incredible so um one of the uh dentists on dental uh wrote um let's see what he wrote right here he said um dr paul stadler DDS says uh west Virginia university school of dentistry has become the second school in the nation to offer yomi robotic guided implant surgeries under the guidance of you yours truly and he says that makes me so proud as a wvu alumni to hear this happy news um what what made you um you know like the vaccine um my 82 year old mother is like oh you know I’m gonna I’m gonna wait till everybody else takes it see if and see if it works I’m like mom you're 82 you don't have time to wait um there's 56 dental schools how come you didn't sit there and say yeah let the first 10 or 12 try it what made you want to be number two and um and jump on it early because i wanted to be part of the development and have experience with research and especially regarding input immediate loading and all this come very well together as well as digital workflow at double view we also have like many other schools we have our 3d printing system the residents are trained on digital planning on on the software they print out their own their their guides we print out the rendering of the jaws to do the regenerative to make our own generative device so it is a is a very exciting environment that's that's what the kids loves and i try i hope i will be able to evolve also the pre-doctoral group and we are creating like a selective selective group of students that are interested in that unfortunately kovit kind of uh destroyed our plan for that education but i think that that's going to be soon resumed and it's all you know I’m not saying this is the answer but i rather again you have to embrace technology you cannot push back i heard a lot of colleagues oh yeah but you know you can do that freehand faster yeah that's true i can do an i can place an implant faster and without going through to the setting up of the computer of the robot but the level of precision that i have with that is you cannot compare to anything else at this point we are under uh the super millimetric level compared to the guided surges is within one to two millimeters so we are looking at a very uh sophisticated device it needs a lot of work still in development that's for sure that's why we like to have it uh to be among the first one uh right in the way right and when you talk to the uh the ceo of um um yomi um the actual name of the company is uh neosis who makes the yomi robot um and he's got a PhD just like you um is he is he excited about the work level the the the product um how would you say it's going i mean there's definitely dentists on dental town that are have bought it and using it and and i and i i gotta ask them i don't want to hurt your feelings or anything but you know when lasers came out my first laser i bought it because uh it was a marketing thing i mean i i mean people were calling up my office saying well does he use laser so you know what i did it was 1987 and the um the yag the indie yag laser just came out it was 50 000 they sold a thousand of them and then went out of business and i wanted to buy one for marketing but my friends were saying that it was too much money and it wasn't ready for prime time and eventually went to go bankrupt so i went across the street to radio shack and i bought um four laser pointers which is a helium and i that way i couldn't lie and i told my receptionist if they ask if they have if how he has a laser say he has one in every room and they go wow and they would come in and i did i had a laser in every room but i wasn't going to drop 50 grand and that was in 1987. that's like a hundred grand today but um would you say that um this yomi is ready for prime time or do you think you should buy a laser pointer instead from radio shack no i mean again the concept this is a very is a very new technology that is not new um is new for for dentistry not new in medicine remember that in medical and in medicine robotic surgery is uh almost everywhere every specialty right now thoracic surgery uh orthopedic surgery they use robotic technology so it's nothing new we just have and actually if you think about it one of the areas that robotic can really be used everywhere is uh dentistry because you have uh we need the sub-millimetric precision and that's what the robot can offer well I’ll tell you what i almost i almost cried watching the news last night that's how silly i am but basically long story short there was a doctor um treating a patient and it got way over their head but they could immediately went into telemedicine and got a experienced surgeon who just specialized on this rare thing a thousand miles away and she could watch and talk her through the surgery so the surgeon's hands were listening to the experience and anyway this kid's life was saved from telemedicine yeah again we have an amazing uh stage right now and uh and it can only get better just a question of putin and regarding the germany right now the yomi right now we have like about 64 65 clinics in the in the us that are using it all type of specialty both a lot of general dentists we have i know there are like oral surgeons some periodontists and again the application is not fully fully exploited i guess they are start working we start working on fully endless cases but again the algorithm the technology is already there for like instead of going to recognizing the the jaws using the cbct scan like we're doing now in few years that may be just a scanner photographic scanner and you know and you can get expedite expedite the process think about what happened with the with the guidance system with the interaural scanners all that is incorporated in in this type of technology so again it's better to be part of it first so you can evolve with that and especially when when i have to train and expose the younger generation well speaking of the younger generation um you know it's a lot easier to learn um sine cosine and tangent while you're alone in a library than when you're with a patient in a retail setting and that when the patients come in they want those implants placed and immediate loaded right away and i want to tell the young kids that you're the doctor you're the dog and you wag the tail and the patient is the tail but when you come out of school and you're a baby you're 25 and you get some 60 year old hyper aggressive guy like me and he's like no no no just do it this way do it that way and sometimes um they talk you into doing things and in fact a lot of lawsuits i see with the young kids the first thing you say is oh i i knew i shouldn't have done this i didn't want to do it i told the patient i didn't want to do it but he talked me into doing it so so i wanted what's the low down on immediate on implant immediate loading obviously they see the commercials on clear choice where they take a surgeon plus the prosthetist plus the lab tech they took one plus one plus one and i say it didn't equal three equals five because that's how many times that company's been bought and sold it's been so lucrative but implant immediate loading when is it a good idea to immediate load and when is it not a good idea i i feel that there is a lot of as you said a marketing use of this approach and i don't think is a strategy that works for everyone um and we are still working on identifying the the the factors that are favorable for for this district this technique is just a technique we are not talking about a religion it's a technique it's like it's like anything else you have an instrument you have as you may you mentioned the laser you you may have i mean i don't I’m not a I’m training laser uh on on the user laser but i think has a very limited indications i mean and is not like it's not going to change your life um same as immediate loading we have situation where immediate loading uh gives it gives you an advantage in particular like in the aesthetic zone when you have big biotype and you want to uh have a better response on the soft tissue immediate loading immediate provisionalization immediate placement media presentation seems to be good we did some study where actually we showed that immediate application of loading grid used their remodeling of uh of the bone around implants of course that's improved that the quality of life of the patient it doesn't have to stay in provisionals on denture for a long time but yet patient selection uh planning and execution become even more critical when you use immediate body and you have to be aware that you have a higher chance of having complications and failures so patient selection planning and what execution and execution you have to be very precise you have to make sure that stability of the implant is optimal the prosthesis have to be passive and well balanced in occlusion and all those parameters as you said a model a business model that use immediate loading must you have four special on board to execute and those four specialists be oral surgeon periodontists prosthodontists and and and laptix and lab techs okay yeah and as far as you said patient selection planning and execution if you saw some of my uh implant surgeries you would execute me uh i am trying to get better at tooth extraction that way i can just uh extract all my filled root canals uh you know uh but um my gosh um um you said so many things um i want to say on laser just one thing i mean my goal is to try to get you in so much trouble um it's dentistry uncensored because i don't want to talk about anything that everyone agrees on and i want to go after where the dentists are arguing hot and when you said laser and you're a periodontist what about that dental laser there's a dental laser they're selling out there for a hundred and thirty five thousand dollars and some people just swear by it and other people are like that's a lot of money doc i i just graduated four hundred thousand dollars in student loans um what do you think of these uh millennium laser uh perillas um um for a hundred and thirty five thousand dollars is that you got two doctorates what is your bill I’m used to buy on evidence okay i try to uh i strive to use my practice based on evidence now when i talk to people that use millennium laser and i have some of my former residents that have because of marketing reason have they have to get the certificate to get higher in the practice I’m not saying it doesn't work it works like modified women's flap or skin root plain that's what the literature shows so you want to buy 130 000 scalar is up to you now uh there is a component that i think is important is the patient uh uh patient-centered outcome patient-like laser because is less painful than the traditional surgery so one you can get you can have higher compliance on the patient coming back to do additional procedure people that advocate the laser especially the the the nd yag with a linup lead to regeneration they have to show me a randomized control clinical trial to prove that there's some anecdotal data but they can you can then regenerate or anything you can there's some study by my friend nibali from uh from the king college in london that shows five millimeter bone regeneration vertical defect using just scaling your root planing so um it's just a tool as anything else and uh you may have a location for that treatment but we don't know what make me a little nervous when we talk about the lean up and peep and all this type of treatment is that they haven't produced despite they have been around for more than 20 years they haven't produced one convincing study from independent researchers that shows that are superior to all the treatments they are maybe equivalent but uh the rest exactly and you know kids another another thing i heard him say is um you know like you'll you'll want to learn occlusion and like like dental town has 400 online ce courses for like 36 dollars that's not even the cab fared airport but to learn something you'll you'll take a cab to the airport you'll fly clear across the country you'll stay in a resort and you'll drop three thousand dollars on a weekend course and then the next weekend I’ll get you in a bar and we'll be drinking beers and having hamburgers and I’ll pull out a bar napkin and a pen and I’ll just say tell me everything you learned i mean I’m ready right i can't even fill up a bar napkin and they dropped three thousand dollars it's like be um be spend your money better there's uh he just basically said that the nap was a 135 000 scalar um why don't you now now if it's a marketing thing that that's totally different i i do know my podiatrist my podiatrist friend he advertised all over laser foot surgery and they come in and he'd rather just use a scalpel in his deal but he used the laser he says it takes some more time it's slower but so it's a big marketing thing for him and uh so there's it's it's a multi-complex still um another thing the the kids ask is um are you implant agnostic or is there uh is there a success reason of why i should pay more money for a premium implant or some of these like lately strawman they own a very expensive strawman but they own the low-cost neoden out of brazil i mean when do you when when should you spend money on premium and when would the the southwest airlines value implant still gets you to grandma's house in time for christmas yeah well that's a story that comes uh comes a long way and we always try to negotiate you know quality versus costs and there's no doubt that this more famous brand they have they've been investing a lot of money in research to improve quality to improve outcome and to you know research and development that's expensive I’m looking for I’m the one doing research on the other side so i have to push that agenda and the problem is as long as we have a situation where uh the product has um um evidence and support and it also has technical support because sometimes you go with these uh less famous brands and they they got more out of the market and you don't find the parts to to to treat the patient that now they have implants that nobody can restore or replace a screw on a button so i always try to stay with a larger brand larger company for for different reasons i think is a sophisticated treatment and one thing that should be like brony mark used to do he basically uh used the traditional bronemark titanium machine titanium screw he was selling it very cheap from brazil so maybe these companies they have this super duper high-end uh product they should they always have the the standard product that is a little bit more convenient if you want to look at the the cost of the material as far as you make the example of the strawman if you buy the the traditional tissue level with the regular sla is like one-third the cost of the blx for instance but to me um it's also interesting like you take the um some of the biggest dental companies in the world like um um you know danaher spun off their dental division and it's called in vista and if you go to invistaco.com they always have the um you know they own um cave occur noble biocare but they also own implants direct so you see um these companies they're kind of like hedge funds they're kind of hedging their bets they're saying on the one hand um you know we want to sell I’m sure they want to would rather just sell noble biocare but they see the other the the values segment and they and they have an implant if you want to place an implant in your mouth which implant you want um which one would i want oh my god well jerry uh jerry um the founder of implants direct has been on this show and listened to it so uh um i know I’m supposed to say noble bio care but jerry jerry resnick would get very mad if i didn't say uh implants direct um but which one would you want would you would you go with a noble biocare or would you go with uh i have one and he's a noble biochar i have it i have it in the mouth for like more than 20 years and have 0.5 millimeter bone loss around it and it's perfect security tane titanium machine [Music] noble bio care so you go in obamacare well well i had no barker so probably today i will go with strawman yeah with the data out of you know if you're familiar with the large paper by uh derk from sweden yeah are you familiar with that they did a large study on you know then in sweden they have the data bank everybody the police implant because they're paid by the government have to report they have like a registry of implant placed so he went to the registry look at 10 years of success and failure of different all the brands that they use over there and yeah strawman came out with pretty with the highest number can you email me that paper uh sure you you said it's a it's a new paper being published no no it's not new it's uh it's a few years old oh it's two years old yeah i i would love to read that that that is amazing but you know they look at 9000 implant over [Music] 20 years so but i think it's interesting like um if you go to investiga investico.com and and which is uh in vista e and vista that's what danaher spent off and you look at their um deals like um you'll see noble bio care but you won't even see uh implants direct i mean they they own the company because there's just more margin uh on these bigger ones so i mean it's oh well the other the other thing is uh you know the is costly and everything but the margin that we put on on placing an implant for some of us is like 15 minutes work is very high my favorite crown and bridge though the the what i love the most crown bridge is when you're doing a three unit bridge and that that that crown in the middle you get a bill full price for the crown and you don't have to prep or pack cord i mean is that that that is my favorite crown and then you implant guys want to get rid of that that crown my favorite crown where i didn't have to do anything but by the way um you know um how they say you know you're not supposed to shame people fat shame people you know make jokes about them whatever i see a lot of shaming going on in dentistry for anybody that does a three unit bridge i mean some people are some people say they should be illegal some people say that you're a that is not true there are indication and communication for everything if i have two teeth they have large restorations and and in between one tooth is missing there is still to me there is still justification of doing a three unit bridge it is well performed they last uh the same as uh as an implant now going going larger with bridges like with like you know uh dual batman and all those kind of things no but the traditional per unit bridge is still even in the front but now somebody's going to have a heart attack but um you know I’m coming from europe and i had some friend there like fantastic latex and the quality of this of the aesthetics in the in the anterior teeth is amazing and again uh i still think that a three unit bridge in the interior region if the adjacent batman needs crown is still um my favorite option especially when the aesthetic is a challenge implants is not an easy aesthetic treatment it requires a lot of works to develop as aesthetic sites I’m going to hold your feet to the fire to this answer because my gosh when you hear dentists talk about what percent of the population has gum disease and what percent of the implants have gum disease i mean the numbers are anywhere i mean people i mean there's people saying that half of america has gum disease and it's like really half there's 330 million people um implants some people say you know that at five years fifty percent of them have gum disease and uh wha wha what statistics would you say for what percent of americans or earthlings you know either 8 billion earthlings or 321 million americans what percent of america do you think has gum disease well as per definition the so if you have two sides with more than uh with attachment loss in the mouth non-adjacent side with the attachments in the mouth the percentage of of periodontitis is for sure up to 50 if you look at the statistic now we're talking about two sites with attachment laws okay we're not talking about pockets that's already the definition case definition of periodontitis when we're looking at the severe disease so the one that needs the periodontist intervention then we are looking at way less we talk about eight ten percent well that number just got a lot smaller so you're saying the formal definition of gum disease is two sides of the tooth have a loss of attachment and based on that definition be half of america but only eight percent would have periodontal disease severe parental disease uh if you talk about periodontitis okay if you talk about periodontitis uh 50 percent have parenthetics but about um the aggressive form is about eight percent okay well here here's the exact question that she's emailing me a lot is you know she sees a patient they have implants placed five ten years ago she's it's it's a bloody perio mess underneath it and the patient has no pain and can go through the drive-through and eat a whopper with cheese and loves it and she's hearing about oral systemic link and she's like well if I’m leaving all this infection is that getting in his blood heart alzheimer's whatever um help her look at this patient in the chair and when when would you factor in oral systemic length and and periodontitis and this implant that's asymptomatic that the patient loves needs to actually be have something done to it taken out replace repaired whatever well for sure chronic infection or active infection with past implants is different pain plantation is different in peripheritis because you have the infection penetrated directly the bone and the presence of this artificial material supports the proliferation of some bacteria that are not present around the parental pocket and you have way more frequent superation and another thing is when you have infection the ph of the of the uh area of the site go lower and increase the amount of release of metal ions in the bloodstream there are studies that showed that patients are pre-implantitis they have high level of titanium metals in their bloodstream so which is not very good you know titanium is inert and stays with no arm in the body but only if it's if there's is in a healthy situation so going back to the relation with systemic condition and periodontitis for sure there are situations that get worse in presence of parentitis and systemic conditions that accelerate periodontitis for instance if you have a rheumatoid arthritis and periodontitis your rheumatoid arthritis get more severe okay because you increase the burden of overall systemic inflammation if um on the other hand if you have an uncontrolled diabetes you have a severe sequelae on the parental condition periodontal disease become more severe with more frequent abscess rapid bone loss and and so forth and so on so um for sure the key is controlling the infection no matter what you do you control the infection you you do good to your patient and there are different means of doing it does not be necessarily surgical you can get very good results with oral hygiene instruction non-surgical therapy combination of anti-systemic antibiotics now there are more and more evidence that the use of systemic antibiotics in combination with non-surgical therapy improve the condition of the mouth but there's a lot of issues and controversies in united states because of the the of course you want to try to reduce the use of of antibiotics disease is a systemic disease it's a systemic infection and as such should be treated also with the chemotherapeutic device um when you and i know this is a crazy question but when you talk about peri implant mucositis or peri implant um do you put a hyphen between perry implant or do you make perry implant one word do you do perry yeah i think the iphone you use hyphen so um on this and do you uh same thing on perry implant titus i mean is that do you also do a hyphen there or or just go uh no i can i now got me in a in a soft spot i think is uh but but um because there's very uh um i think it's a peri-implant mucosite is yeah i think it's very hyphen i think so there's peri-implant mucositis um and then there's uh peri-implantitis yeah and um so do you um could you talk about the difference between those two how you diagnose them or treatment and which one which one concerns you a lot and you know okay pre-employment scientists is as as in case of pain and periodontitis is the beginning of uh the inflammatory process so patients that has um inflammation around the implant consistent information of the implant have a higher chance of evolving versus loss of bones or paired on perimplantitis the definite the the case definition of mucus site for implementation is the presence of bleeding upon probing with no bone loss around the implant and of course the metrics of defining bone loss you consider the bone loss when you have a radiographic bone remodeling around the implant less than uh 1.1 millimeter after the first year function and um no more than three millimeter if you look at the cross-sectional as assessment no more than two millimeters I’m sorry after a concessional assessment so when there is no bone loss and there is a bleeding on probing and that is uh mucositis the probing depth depends on what is the base position of the implant so you should have a baseline records on that but if there is no bone loss and even if you probe five six millimeter which is sometime happening in anterior implants you can uh and there is no bone loss but there is bleeding improving that's mucositis as soon as you start losing bone more than two millimeter from the platinum of the implant that periplantitis if it's associated with bleeding and separation and what about um you're young you're a young dentist you only went to dental school because your mom is a dentist you're back with your mom you go to courses and i think every dental course you go there's some people in the course a little more excitable than others but some people still say that periodontal disease is irreversible once you lose the bone you can't grow back other people are saying it's regenerational you're a bone biology expert with two doctorates is periodontal disease bone loss irreversible or not well always there are multiple evidence you can rebuild the bone and but more than the bone in periodontal disease is important to re recreate the parental attachment bone can remineralize and partially recover or repair but what you need to have is the new attachment around the tooth so but we have evidence multiple evidence that that can be obtained uh that the problem is how much what is the level or and the predictability of achieving that and then we're gonna go in a more complicated conversation but the answer is yes you can regenerate bone you can regenerate parental ligament you can use different technique and technology from grafting biologics combination of grafting and biologics and the problem is patient selection defect selection and surgical technique huh you're um it's like listening to beethoven play the piano bone grafting when i was a little kid and got out of dental school in 87 um there was um the big the big miracle drug was um gosh or the bmp bone morphological protein and they were doing study studies and monkeys but they i guess in argentina and they found out that my it was very dose dependent if you use too much bmp some of those monkeys were growing other things in their bone um what is bone biology that that's that was my introduction in in 87 what does bone biology look like to you today well still uh there's a lot of uh exciting area of development and especially in a growth factor department and bnp is still the one of the best device biologics that lead bone regeneration the problem is you can only regenerate bone not ligament so it doesn't apply to treat parental defects it does apply to treat bone deficiencies in case you want to rebuild um area for implant purposes and some case report even show uh the only situation where you can actually have aussie rios integration of the implant that's been exposed to pain periplantitis by using bmp and one of my old good friend of wikishow which is uh the gurus of bmp has done most of the pre-clinical research on that material and it's still still we don't have a specific protocol from that and uh as you said is those dependent uh we use the dosage that they're using orthopedics but it's too much for for the the application dental so the problem now is the cost as soon as the patent for those medication goes allowed a lower cost i think we will see more extended use of bmp and again another important thing to say about bmp bmp is a is uh uh not um um mythogenic growth factor it doesn't produce cell proliferation it does a control the cell differentiation from from the indifferential cell to osteoblast and so that it's not as uh some of the things that were brought up about bmp is the risk of cancerogenic effect uh is less than other uh other growth factors but I’m not a specialist or growth factor this is just saying what what i know about it i had um carl mish on the show before he passed away and that um podcast um didn't set well with a lot of implantologists who uh he didn't like his remarks uh and you know um carl he just uh tell it like it is and when he was um you know in his last few months of life um he really told it like it is kind of a brutal deal but he he called when people were drawing blood and spinning it and doing all this stuff he called that voodoo he said you know um i don't i don't i don't mind i don't mind that not for i mean voodoo for bone formation perhaps yes there are some interesting data and we are using this one here 2w and all other universities uh instead of using the famous prp uh we're using prf and there are some more uh you know data suggesting that the prf is a little bit more uh supportive but the bottom line is what you do with this product is to increase the stability of the blood clot and stimulate proliferation of the cells of the epithelium so you basically protect your graft much better okay and then there's some indication that you have you keep a lot of nutrients for for the cells that kind of boost a little bit the early phase of healing which is the key the healing phase of healing is the key after that everything goes normalized go to plateau um there's a lot of kids that are uh in school and I’m a big proponent of specialization because it's pretty obvious that in 1900 uh healthcare was only one percent of the gdp and in 2000 it was 14 of gdp now it's 2020 it's 17 percent of gdp but in the year 2000 there were no specialties and then by the end of that century from 1900 to 2000 the mds had 58 we had eight now it's 20 20. the dentists are already up to 12. i mean i just don't see us going back in time where one doctor delivers your baby amputates your leg pulls your tooth and gives you a haircut to boot um but when i look at all the specialties my gosh i mean oral surgery and opera you're the grad uh guru of west Virginia university uh for the graduate periodontal program but my god i look at your program and periodontics i mean it's been under more changes in stress in my 32 years than pediatric dentistry or endodontics i mean when i got out of school it was all all these neat ways to save the tooth and bifurcations and sectioning teeth and then i got out in 87 then about early 90s people said you know what the best periodontal treatment is just throw the damn tooth away and replace it with titanium and that was that was magic walk for about 10 years and everybody started saying oh wow well we still got periodontal disease and now i see it going back to just like it was 30 years ago where now you send a case to the periodontist you know he's going to say pull he's like you know what let's let's do this i mean they're going to great lengths to save a human tooth i mean it's like it's like it's done at 360. so where are you at right now this is what i think we have parental diseases is not a tooth based disease this is what somebody sometimes people especially in general dances get a little confused like oh parental disease i see because there you used to look at a single tooth with a decay the crown the pulse the endo parental disease is a systemic condition that involved is the patient that has has that condition and so you have to direct that problem in particular patient we're going to customize medicine that's what it is you have to address the respect of the particular patient you have to implement all the technique to treat that patient now saving or teeth on parental patient versus extracting teeth and placing implants what is better i got a presentation a lecture on that if you want to um i would be honored to have a presentation from you i mean you're if you look at the literature throughout these 50 years of periodontics we are proven proven and prove it again that we can maintain dentition in function for very long time okay data show that parental therapy can maintain the intuition even with severe compromised bone loss for very long time of course you need to implement all the um the device and the technique but and have a great patient compliance now the question is is it better to take the teeth out and place in plan instead to implementing the the treatment also from a cost standpoint study shows that maintenance parental therapy maintenance is most cost beneficial for the patient provided the patient maintain that now if i strike the teeth and a place implying on a patient that suffer that i've lost it for parental disease do we have the same certainty that those implants stays for long time in that patient mouth that depends on the patient age and how much years of service we're gonna ask to those implants uh so if i have a patient that is a aggressive paranoid aggressive disease is um losing teeth at the age of 30 if i take the all the teeth out and i place implant if you look at the possibility of having pairing plantations in this patient is significantly higher and the bone loss when you start around an implant you know that is very fast so the trick is to use parental science to maintain the dentition in a younger individual with severe periodontitis so yeah you push back as much as possible the time you're going to replace those teeth with the implants vice versa in an older individual maybe have more more sense to rehabilitate the mouth using implant because the the time of service you ask to the implant is less that's one of the strategy the problem is we know what to do around a dentition with parentitis we don't know what to do around a full arch rehabilitation with pair implantitis and you've seen these cases that goes around after five years more than seventy percent of bone loss around those implants supervision everywhere patient has spent fifty thousand dollars for rehabilitation now everything has to we have to do start over again that is something that every time we approach the full mouth extraction uh on these patients we have to think about it now one thing we don't know is does the removal of teeth change the biofilm of the patient that's susceptible to periodontitis and is that beneficial we don't know yet we have just no data on that information if that is the case then makes sense switching from the teeth to implants but then you have to still control the uh the risk factors to make sure that the treatment is successful in the long term now i want to be i want to be perfectly clear that this question this next question has nothing to do with me nothing to do with me but now a guy's ass on dental town is it true that treating gum disease and oral health can cure erectile dysfunction there's been some data on that um uh the reduction of sierra of the serial active pro crp and all the pro-inflammatory cytokines that can be produced uh due to a severe infection can have an effect on the overall well-being now do we have there's some association that individuals with erectile dysfunction have higher periodontitis but the effect of treatment the effect on treatment on er is unclear oh and again that had that was not me that was uh i was asking for a friend always I’m just kidding um another one um one of the biggest debates on dental town is um this oral systemic link and so many people believe this oral systemic link just like on erectile dysfunction i mean it sounds pretty obvious to me that if you had a mouthful of perio and pus an infection you might have some issues um but um can you factually say that anything is absolutely the oral systemic link um uh causation or is it still correlation or yet to be determined or where are you at with that now well there are some conditions that have a stronger interaction like as i mentioned earlier some strong data supporting the fact that if you have a rheumatoid arthritis and parental disease you have more mobility due to the to the rheumatoid arthritis so there is an impact on inflammatory burden that contribute to the pain that you have in your joint or your inflammatory episode and all that um there is a significant there is a very important uh study by francesco dayuto from the eastman from the eastman institute in london that proved that parental therapy significantly reduce a1c in diabetes in diabetic patient and that is a very well-run study that shows that uh active parental therapy I’m talking about extraction hopeless teeth skin planing surgery removal of pockets or real not just scaling your plan just real treatment has a significant impact on a1c value and remember that a reduction of 0.6 on a1c reverberate on 15 years of life expectancy over the latex patients so that's a lot and he was able to reduce the a1c up to 0.8 so that's very significant then there are some other errors a little bit more unclear like the interaction between cardiovascular [Music] preterm birth and uh they just show association uh and um that can very well be but there are a lot of other factors that come into play and it's difficult to have a clear-cut other areas that can be that shows um correlate and correlation actual the effect of treatment because what i think is okay if there is a correlation it means that if i treat the disease i haven't improved right so that is for diabetes that uh and the same seems to be also for like chronic kidney disease as well uh well I’ll tell you what when i see saw that ed um article that uh i thought that might be a new growth area for dentistry right wrong kyle just threw up his eyes he's uh he's gonna he's had it for the day uh my gosh um that was uh so interesting and i know we went over in the merging era for the thing I’m sorry to interrupt this alzheimer's there's a lot of good results showing that uh um presence of uh pg g valley's proteins seems to be involved in alzheimer's degeneration so we are doing studies here too on that yeah i am um so my mom is 82 and she's concerned she was losing her memory and she asked me if i thought she was getting alzheimer's so what i did is i just went over to her house and told her i was taking out for dinner but i drove her way out in the middle of a farm field and kicked her out of the car and um to see if she found her way back home and she did so i said okay mom you're good you found your way back home so i told her once a week I’m just going to drive her out in the middle of the farm field um um i got to ask you another question um and i know we went over the hour or can i go into some overtime or do you got to get back to class okay um the um digital dentistry and implant dentistry i mean there's a lot of old school guys like me who are 58 who say i just want to use my vinyl poly siloxane i want to use my amper gum and um but some people are saying that you know you got to get into the into the oral scanners and there's some people that that the entire dental implant process is digital from a to z um where where are you at with the digital implant process i mean are you still using rubber base and volley panel siloxin or is everything a scan to you now well uh again I’m not I’m not doing frost here uh but I’m involved in the imp I’m the chair of the implant course um we use both while we are doing more and more um intraoral scanning and developing more digital workflow patient likes it better and once you get used to it is uh is a is a it is a faster process it's faster to communicate to the with the lab and with the cad cam machine you can do most of the work even in your own office well and um and then the other question which i i hate to ask you because it's so it's so vague a lot a lot of people are saying that um for treating periodontal disease and all that stuff that that cbct three-dimensional is the standard of care and that the 2d pano is not do you are you what would you think of that statement when someone says you need a cbct 3d to do perio i think a little bit too much there are some application where you want to you may want to have a small volume cbct to assess for instance if you do amputation or you want to manage your forcation or stuff like that or especially for immediate placement of dental implants but yet to date the the uh treatment the diagnostics for for uh for teeth uh in parental conditions is the full mouth pa there are some issues still with the cbct scan um there are limitations in detecting the alveolar bone on the on the buccal aspect and that interproximal region can be difficult to identify the anatomy but some study shows that for instance if you have to identify for occasions and you want to decide you're going to cut the root or any second tooth um cbct scan seems to be the best treatment uh the best diagnostic to you know identify what treatment is best for the patient and since you're um running the periodontal department um some people are thinking that due to corona cover 19 that the ultrasonic scaler is causing too much aerosols and that it's time that srp goes back to hand um what do you what do you think about that well here for for what we do we try to give uh we we try to give priority to hand instrumentation so that there is less danger to to spray around aerosol that's for sure uh the use of aerosol um our days with the kovid is a problematic um whether in your answer there was whether the sonic ultrasonic is better than uh hand instrumentation for or worse and better and hand instrumentation for a perio concern there is no differences it's just a question of probably fatigue and time you if you use a power driven you're faster and there's but the outcome if it's done properly it doesn't show any difference ah um my gosh i could ask you questions for 40 days and 40 nights i can't we went over the hour and I’m uh oh my gosh well we can i can come back oh you come back um i i want to ask you a very controversial question um crown lengthening um every it's it's like eighty percent of the dentist have haven't done it one time in the last one two three four years and then 20 percent do it all the time and then when i go talk to my periodontist friends they say it's the same every periodontist tells me it's like the same five or six or seven guys that send them all the crown lengthenings and then the other ones never even heard of it i mean why first of all do you see that where in west Virginia it's an 80 20 thing oh yeah i mean um goes in waves and it really depends on the evaluation of the resort the dentist and I’m so i have to preach around because especially sometimes you see some restart the dentist they're still thinking that you don't need crown lengthening but then they you have these students doing the impress making the impression like five times to see the margin and then end out having uh under under contour or over contour margin because the impression is poor say guys instead of doing this why you don't send it to us we're gonna give you a nice soft tissue contour the dish is not going to bleed you're going to take the impress the impression with just one uh one layer of retraction core and you're fine and some some get the message it's just a question you know of culture as you said some of my colleagues are very good in educating their referrals and the referrals they're wise enough to get a nicely prepared mouth for their restoration and crown length does that doesn't mean you have to do it all the time you have to be able to identify which case needs that but if you have to force the cord to get the retraction and you still have bleeding that is why you want to send a patient that's my little advice um some of the kids get out of school and they um they go get a job with a dso and I’m not slamming dsos at all i mean i i think they're uh i think competition is good for dentistry and i know in phoenix arizona before dsos there was nobody open on saturday or sunday oh I’m sorry my ignorance oh dental services organization like like aspen or heartland big corporate dentistry and you know big corporate dentistry they have customers and they they create competition but some of the younger dentists they go get a job there and of course insurance you know money's the answer what's the question and when uh look at dental radiological uh radiography rentkin came out invented the x-ray thomas edison looked at it and didn't look at it you know scared the hell out of him especially after what happened to redken so thomas edison even walked away from it um but it lingered on and didn't really enter dentistry until after world war ii uh the longshoremen's club started the first dental insurance company in washington oregon California turned in later to be delta and they covered these x-rays at a hundred percent and the next day every dental office was buying an x-ray machine well these these dsos um they see insurance codes where if you put in monoxycycline or doxycycline or period chips or things like that there's an insurance code so a lot of the dentists are being told by an office manager who's not a periodontist or a dentist and she's a billing and she says well if you're doing root playing curettage you need to put a chip in each one of these because i can bill six 10 12 bucks for each one i want to ask you is that scientifically a good reason or is that only insurance and a money reason i mean the use of topical antibiotics has an application it's not like you want to use but you don't want to use it all the time using those sites that may have they have already received surgery and they you already for some reason you don't want to do surgery and you want to make sure that infection is low you can use it as a you know in a specific cases is an alternative to treatment is again is another weapon in our momentarium you can use they are effective uh although the impact on attachment gain is like 0.2 millimeter average but if you look at for instance you have a patient with a bridge that is fully functional uh you cannot do surgery otherwise you're going to expose the margin and it's going to be difficult to rebuild a smile you have to compromise those are the sites where in addition to the manual scaling you can use this type of technology there's nothing wrong with that using it systematically on everyone just to build them to me is unethical period and then i would just ask your um office manager say well um monoxycycline doxycycline what i want to know is do you recommend that i use hydrogen peroxide or dihydrogen oxide and if she can't answer that uh what's the difference between hydrogen peroxide and dihydrogen oxide well i mean the the materials is available uh uh in u.s is a minicycling which is microsoft was arresting uh the doxycycline jail and I’m not sure this has been approved united states we use them in europe but I’m not sure it's available in the united states um we use arresting um i should disclose that I’m doing research for them so just to and it's not that I’m a favor for that but arresting has a good track record instead of in terms of quality um but um anything works actually pretty much they're all on the same if i have to decide instead of going with the parachutes I’m not i'd rather go with uh thicker cycling type of drug that has more substantivity and is bacterial bactericidal at a high concentration that's what i would do oh my gosh um unbelievable and then um another one and thanks for staying for overtime um you know when i go every time i go to my doctor um you know he always runs blood tests and so it makes me wonder um you know i see all this saliva testing um if if dentists are truly the physicians of the mouth should we be doing more blood testing saliva testing things like that or are you able to do the same diagnostic exam and treatment plan and success rate without blood work or saliva testing do any of these do any of these blood tests or sliver tests affect your treatment well there's been that's a being like the the the quest for the sucker growl for many many years in periodontics to find a marker anywhere in the blood or in a saliva that indicates that your disease is progressing or not we are not there yet there's some these markers goes on and off and the saliva the use of those uh salida tester was very interesting they can map they they can do uh biomix on that so proteomics metabolomics to the saliva they can even there are some studies that show that you can even identify risk factors for pancreatic cancer stuff like that regarding our practice this is what i think we should do as a dentist in general for the seeking of other population of our patients especially in the us where diabetes is a very very [Music] common disease especially is under diagnosed we should use uh you should you should use those a1c tests in the in the dental office and when the patient has a severe disease unexplained periodontal abscesses that's where you want to run a1c tests to see what is the value on that and eventually recommend the patient to their own physician we see patients go to dentists more often to the than going to the physician and the use of this chair side test for especially for a1c value they're very very important um yeah my doctor says that if your a1c is high he knows something's wrong and if he can't find it he's just going to keep looking and looking looking he thinks it's like the mr the mri cat scan all rolled into one um another another controversial thing um around phoenix arizona um a lot of the doctors let's say they're um i don't know maybe they're older doctors but when they see a lot of periodontal teeth they start splinting with ribbond or orthodontic wires things like that and and again it's like crown lengthening it's like you either do that or you never do that um what do you think about all the guys putting uh ribbond and ortho wire and splitting all these teeth together that are periodontal infected good idea not a good idea i mean it's like the occlusion okay the occlusion in parenthesis is being debunked i know there is group in in america where they only everything is about occlusion and all that we don't have any evidence or very weak evidence that uh occlusion alone determine periodontal disease we know that and it's not we want to control you know um contact that are uh a bearing and they create excess parameters accessibility if we can do it but that's for the occlusion i wanted to talk that earlier but now to give me the chance regarding the spleen this printing depends on the patient on the patient comfort splinting shows that it doesn't improve anything besides the patient contract there is no improvement in the ability of the tooth to preserve attachment there is no improvement in reducing mobility what you do you just make the patient more comfortable and you avoid the like exfoliation of it too but then at that point there is another the counterpart is when the splinting become sometimes cumbersome to maintain because it breaks and you have difficulty for the patient to clean and as uh it may interfere with the with a decent occlusion so there's the pros and cons we do that once in a while I’m not a big splinter guy even because if the patient has a class three mobility i may go for a different route well it's funny because you you start off earlier saying that um you know dentistry uh dental implant surgeries it's a technique it's not a religion and uh a lot of the tmj guys it's it's occlusion guys it's a religion yes i mean you just got to be a believer and if you raise your hand and start arguing with them you're not going to have a drinking buddy after the class you have to consider the evidence we are scientists at the end of the day and everything is anecdotal the same as the laser thing um this could this is antidotal evidence it's no study but it seems like when i got to school in 87 i saw a nug all the time and then it's like gone i mean did well you have to come to west Virginia so it's so it's still alive over there oh yeah smoke tobacco stress there's a lot of factors yeah um my gosh i i could talk to you forever you're so amazing um thank you so much uh tell your greek buddy photo that i said hi and i asked him i wanted howard want to know if everybody in that school has to have two doctors because i only have one so i don't think i could ever teach west Virginia but um seriously gian pietro skincolia um thank you so much for taking your precious time to come on my show and talk to my homies about all thing perio would love to have a course on you um i mean my gosh because during the pandemic um online ces exploded because they they don't want to get an airplane they don't want to go to a brick building and that's why the podcast has exploded um i notice um um you know all things virtual are going big in fact that's my final question is um west Virginia uh implementing telemedicine tele-dentistry yeah we actually do and podi is organizing that yeah we start doing that yep all right all right well uh thank you so much for coming on the show i hope you have a wonderful rest of the day thank you for having me and uh let me know what we can do if you want to continue this collaboration about mary I’m very happy to come back